Extended thoracic endovascular aortic repair is optimal therapy in acute complicated type B dissection

J Vasc Surg. 2024 Oct;80(4):1055-1063. doi: 10.1016/j.jvs.2024.05.009. Epub 2024 May 14.

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta.

Methods: Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed.

Results: Extended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P < .01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P = .27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P = .38), 3.2% (5.8% vs 0%; P = .18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P = .04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P = .04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P = .32).

Conclusions: Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.

Keywords: Aortic dissection; Reintervention; Remodeling; Thoracic endovascular aortic repair (TEVAR).

MeSH terms

  • Acute Disease
  • Aged
  • Aorta, Thoracic / diagnostic imaging
  • Aorta, Thoracic / surgery
  • Aortic Aneurysm, Thoracic* / diagnostic imaging
  • Aortic Aneurysm, Thoracic* / mortality
  • Aortic Aneurysm, Thoracic* / surgery
  • Aortic Dissection* / diagnostic imaging
  • Aortic Dissection* / mortality
  • Aortic Dissection* / surgery
  • Blood Vessel Prosthesis
  • Blood Vessel Prosthesis Implantation* / adverse effects
  • Blood Vessel Prosthesis Implantation* / mortality
  • Databases, Factual
  • Endovascular Aneurysm Repair
  • Endovascular Procedures* / adverse effects
  • Endovascular Procedures* / mortality
  • Female
  • Hospital Mortality*
  • Humans
  • Male
  • Middle Aged
  • Postoperative Complications* / etiology
  • Postoperative Complications* / mortality
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Treatment Outcome